This article defines the many critically important details of spondylolisthesis and the impact it has on young athletes. This condition affects young athletes in every community. Dr. Terry Yochum is the national expert on this topic and I had the distinct benefit of lecturing with him and learning from him 55 times over a 9 year period. This information has elevated my care of young athletes to a level of “Expert”, both locally and nationally. I have parents from outside my city and state contacting me and visiting my office to help them with this confusing and misunderstood injury. No profession is better equipped to diagnose or treat this condition than the chiropractic profession.
Young athletes in the 12-20 age group are most vulnerable for a stress reaction or stress fracture in the low back, and most trainers, therapists, chiropractors and physicians don’t know how to accurately diagnose or treat this condition. Many parents of affected young athletes call this journey a complete nightmare and young athletes can miss over a year of sports and activities when mis-diagnosed and treated incorrectly.
First of all, this injury occurs where the stress in the low back is greatest, and most of the time it’s the very low back, L4 and/or L5. The figure below (Fig. 1) shows the biomechanical imbalances every human has (unique to all of us of course), and when combined with repetitive activity, rapid growth, traumas and bad luck, stress injuries occur. And they occur much more frequently than one might imagine.
Definitions: A Stress Reaction is inflammation within the bone (vertebrae) as seen on MRI (Fig. 2) with
no fracture. If signs and symptoms are ignored, such as stabbing back pain that gradually increases in frequency and intensity, this can lead to a Stress Fracture (in the vertebrae this is also known as a pars defect) (Fig. 3) as inflammation weakens and predisposes bone to fracture if activity continues. A Spondylolysis is a unilateral (one-sided) or bilateral (both sides) fracture in the pars/pedicle region without anterior (forward) movement of the vertebrae. A Spondylolisthesis is the anterior (forward) movement of one vertebrae on another, usually secondary to a bilateral fracture in the pars/pedicle region. With regard to a spondylolisthesis, there are several categories. When there is a pars defect combined with bone marrow edema, this is known as an Active Spondylolisthesis. When there is a pars defect in the absence of bone marrow edema, this is known as an Inactive Spondylolisthesis. When there is bone marrow edema in the absence of a pars defect, this is known as a Pending Spondylolisthesis.
Signs and Symptoms: Low back pain that stabs on extension is an indicator. Another indicator is the lack of improvement with rest, physical therapy or chiropractic adjustments. The symptoms can be unilateral or bilateral, just as the bone marrow edema and pars defects can be.
Proper Tests: Standing x-rays will show 2 possibilities-the biomechanical imbalances that contributed to this stress injury in the first place, such as unlevel femoral heads, an anterior Ferguson’s center of gravity line or an increased sacral base angle. If a fracture is seen on x-ray, but the bone has not moved forward or backward, it’s known as a spondylolysis, or pars defect. If the bone has moved forward on the vertebrae above and/or below, it’s then known as a spondylolisthesis. Usually the difference between a spondylolysis and a spondylolisthesis is dependent on a unilateral pars defect vs. a bilateral pars defect.
As helpful and important as the standing x-rays are, the most important test is the MRI. Specifically, a lumbar MRI with a sagittal STIR image. And as crazy as this may sound, the fracture is the 2nd most important concern on the x-ray or MRI. The MRI is the most valuable test to be done because it will show if there is bone marrow edema (bme), or inflammation in the bone. This is the finding that will govern the treatment and recommendations needed. If there is a fracture with no bme, then it is safe for the athlete to play (dependent upon pain level) as the pain is not coming from the fracture. The fracture has healed. The spondylo is an old injury. DO NOT have a CT scan performed on the young athlete as that is recommended by those who think the fracture is the primary problem (CT scans highlight broken bone). The fracture is almost irrelevant, it’s the bme that is highly relevant. CT scans bombard the patient with tremendous dosages of needless radiation (according to Dr. Yochum a CT Scan is equivalent to 50 lumbar x-rays) while the MRI has no negative effects. The MRI will show both the fracture and the edema while the CT Scan will only show the fracture.
Proper Treatment: If the MRI comes back negative for bme, then the source of the pain is most likely a strain/ sprain injury or a disc injury (which will also be seen on the MRI). If there is bme on the MRI report, the appropriate treatment is to take the athlete out of ALL sports and activity for 12-16 weeks and write a script for a Boston Overlap Brace and give it to your local Orthotist. This is a custom fitted brace that wifi put the spine into a flexion position that wifi allow this injury to heal the quickest. The brace should be worn 23 hours/day. The more an athlete can adhere to this regimen, the quicker they wifi heal and be able to return to play. In most cases, the injury wifi not return.
In addition to the above, I use laser therapy (Fig. 4) which helps to reduce inflammation more rapidly. When adjusting this patient, do not adjust the level of involvement, as this bone is more fragile due to the inflammation.
Again, when following the wrong protocols, a young athlete can suffer with back pain for over a year, unable to play sports and suffering significant emotional distress. And, the emotional and financial distress the parents feel is overwhelming. The entire family suffers. Once the pain has reduced, a follow up MRI is recommended. The athlete doesn’t need an entire MRI, they only need the STIR image to see if the bme has resolved. Request your MRI facility to do this test (Lumbar Sagittal STIR Image) for a small amount of out of pocket money as this test takes less than 5 minutes. Most facilities will do this test for $100. Insurances will not cover this, but this test guarantees the inflammation is gone and is important before sending an athlete back to play.
Final Step: Perform a biomechanical exam (Structural Fingerprint® Exam) to determine why this injury occurred in the first place. A digital laser foot scan with standing A-P and lateral lumbo-sacral x-rays are needed to make appropriate corrections in the patient’s imbalanced biomechanics. The chiropractic profession is the only profession capable of doing this exam. For further information on this exam, visit DrTimMaggs.com.
• There is always inflammation and pain associated with a spondylo. If the patient doesn’t remember ever having pain, it may be this occurred during the toddler years when pain didn’t register.
• No one has ever been born with a spondylo. It occurs post birth.
• Once a spondylo has healed and there is no more pain or inflammation, the bone is stronger than prior to the break. Allow the young athletes to participate in full activity and sport.
• There are increased vulnerabilities when an anterior Ferguson’s gravity line and an increased sacral base angle is present.
Dr. Tim Maggs has been in private practice for 44 years in upstate New York. He specializes in the diagnosis and treatment of sports injuries. He established the Concerned Parents of Young Athletes™ (CPOYA) Program and the Biomechanical Analytics™ Certification Program. He partnered with Foot Levelers to develop their CPOYA custom orthotic and has traveled to over 100 cities conducting seminars on his Structural Management® Program. He can be reached at [email protected]
1. Yochum TR, Rowe LJ\ Barry MS, Maola CJ, Kettner NW. “Natural History of Spondylolysis and Spondylolisthesis”: Essentials of Skeletal Radiology. 3rd ed, Williams & Wilkins, Baltimore, Maryland, 2005